Abstract
Background:
Coronavirus diesease (COVID-19) led to increased demand on the Indian health system due to the pandemic as well as other communicable and non-communicable diseases. Guidance was thus issued by the Ministry of Health and Family Welfare (MoHFW), India, in April 2020 to maintain the delivery of essential health services.
Objectives:
To determine the extent of disruptions of essential healthcare services, identify associated factors, and establish pertinent correlations to address specific needs.
Methods:
The Mother and child tracking facilitation centre (MCTFC) conducted a telephonic survey with the front-line workers (FLWs) and beneficiaries in 21 Indian states. The sample size was determined using the infinite population sample size formula, and respondents were selected through a computer-generated random sequence technique. Data were quantitatively analysed using STATA-16. Descriptive univariate analysis was conducted using the Chi-square test.
Findings:
The majority of the essential health services were being satisfactorily delivered by FLWs (N = 1596; accredited social health activist (ASHA) = 798, auxiliary nurse midwife (ANM) = 798), where most of the beneficiaries (N = 1410; Pregnant Women = 708, Postnatal Women = 702) continued accessing services with minor issues concerning referral transport. FLWs reported issues in the provisioning of medicines (P = 0.000) for patients with non-communicable diseases and more ANMs than ASHAs reported it. FLWs commonly experienced challenges in extending services due to community resistance and unavailability of general health services at healthcare facilities, where a greater number of ASHAs faced it (P = 0.000). Both FLWs and beneficiaries (N = 3006; FLWs = 1596, beneficiaries = 1410) demonstrated appropriate COVID-19 knowledge and behavior.
Conclusion:
Although overwhelmed, the Indian health system performed satisfactorily well during pandemic in terms of essential health services.
Keywords: ANM, ASHA, COVID-19, essential health services, India, postnatal women, pregnant women, Primary level
Introduction
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), identified as the causative agent for the Coronavirus disease (COVID-19) has spread rapidly worldwide.[1] Globally, as of 30 August, 2021, there have been 216,303,376 confirmed cases of COVID-19, including 44,98,451 deaths, reported by WHO.[2] Although global vaccination efforts have successfully vaccinated 5,01,99,07,027 people worldwide, the population that needs to be vaccinated against the virus to initiate ‘herd immunity’ is unknown.[2]
The COVID-19 pandemic has generated a rapidly increasing demand on the health systems across the world.[3] Low and middle-income countries (LMICs) are particularly suffering several setbacks due to the heavy burden of disease and severely under-resourced healthcare systems.[4] With several challenges subsequently plaguing the Indian health system, our health facilities and workforce are inundated by a plethora of activities related to controlling the pandemic.[3] When health systems are overwhelmed, both direct mortality from an outbreak and indirect mortality from vaccine-preventable and treatable conditions increase dramatically.[2] The Ebola outbreak is a prominent example of how outbreaks may disrupt essential health services, increasing mortality from preventable and treatable conditions.[5,6] As per general perception, the COVID-19 pandemic is highly likely to defer the delivery of essential health services owing to perceptions that health facilities may be infected. Previous studies have established that essential health services have been severely impacted in India and globally, and LMICs are witnessing the most disruptions.[7,8]
To mitigate the devastating impact of COVID-19 on the Indian health system, the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI) issued guidance[9] in April 2020 to maintain the delivery of essential health services during the pandemic. The term ‘‘essential services’’ incorporates services for all areas, including reproductive, maternal, newborn, and child health (RMNCH), prevention and management of communicable diseases, treatment for chronic diseases to avoid complications and emergencies. A telephonic survey was conducted to assess the service delivery and access to essential non-COVID related services during the COVID-19 pandemic; identify the facilitators and barriers experienced by the front-line workers (FLWs) while delivering essential healthcare services during the COVID-19 pandemic, and determine the knowledge and practices of the FLWs and the beneficiaries related to the COVID-19 pandemic. The aim was to determine the extent of disruptions of essential healthcare services, identify associated factors and establish pertinent correlations which will potentially facilitate addressing and providing inputs for specific needs and considerations for essential health services in compliance with the GOI/MoHFW guidance in the context of the COVID-19 pandemic.
Methodology
In view of the ongoing pandemic, a telephonic survey was considered most appropriate. The Mother and Child Tracking Facilitation Centre (MCTFC), established by the MoHFW, GOI, undertook the survey using the contact details provided through an existing database. A semi-structured interview schedule was constructed and created with the help of a pre-existing software at MCTFC. A pilot study was conducted to test the study’s reliability and validity in four states: Delhi, Punjab, Uttar Pradesh, and Kerala, and instruments were duly modified. The calling agents for respective regional dialects were recruited and trained on the objectives and survey tools. The agents were monitored for quality during the interviews. All responses were entered in a computer-based online form developed for this purpose, and data collected were stored back-end of the system automatically after the end of each interview.
Primary respondents for the assessment included the FLWs (ASHA and ANM) and the beneficiaries (women in their antenatal and postnatal period). The ASHA and ANM were specifically selected because they are community health workers instituted to deliver essential health services in the country. Women in their antenatal and postnatal periods were selected as RMNCH services, including a huge proportion of the essential health services delivered in India. Twenty-one (21) Indian States: Chhattisgarh, Haryana, Punjab, Andhra Pradesh, Uttar Pradesh, Rajasthan, Madhya Pradesh, Delhi, Bihar, Tamil Nadu, Kerala, Uttarakhand, Maharashtra, Odisha, Gujarat, Telangana, Assam, Karnataka, Jharkhand, Jammu and Kashmir, West Bengal were included based on the COVID-19 caseload as in April 2020. Likewise, one district within each state with the maximum caseload was selected for the study.
The sample size was determined using the sample size formula for an infinite population with a 95% confidence interval (CI) and a margin error of 5% using 1.96 z score for 95% CI. For that, 800 participants for each category were recruited. A computer-generated random sequence technique was used for the selection of respondents based on the list maintained by MCTFC to represent the target population and eliminate selection bias. Data were analyzed using STATA version 16. A descriptive univariate analysis was conducted using the Chi-square test for indicators that were common among a selected group of respondents. An alpha level of 0.05 was used to determine the statistical significance.
Ethical clearance was obtained from the Institutional Review Board, National Institute of Health and Family Welfare, New Delhi, India.
Findings
Delivery of essential non-COVID services
A univariate descriptive analysis concerning the service delivery variables established that despite the prevailing conditions, most of the essential services were satisfactorily delivered by the FLWs. Comparatively, the provision of medicines for non-communicable disease (NCD) patients and routine immunization (RI) services through outreach services were lower. Although the provision of medicines for NCD patients was lesser among both ASHAs and ANMs, more ANMs mentioned that they were unable to undertake it (P = 0.000). Similarly, RI through outreach was lower among both ASHAs and ANMs and lower among ANMs as compared to ASHAs (P = 0.000). A detailed account of service delivery reported by the FLWs is depicted in Table 1.
Table 1.
Service Delivery Indicators – Frontline Workers and Beneficiaries
| Front-line Workers | ASHA (n=798) | ANM (n=798) | P |
|---|---|---|---|
| ANC services | 787 (98.7) | 774 (97.1) | 0.026 |
| Support for institutional delivery | 761 (95.5) | 0 | NA |
| Accompany institutional delivery | 733 (91.2) | 0 | NA |
| Home-based newborn care | 747 (93.7) | 0 | NA |
| Accompany sick newborn to facility | 642 (80.6) | 0 | NA |
| Immunization services | 772 (96.9) | 778 (97.6) | 0.369 |
| Diarrhea in children | 673 (84.5) | 762 (95.6) | 0.000 |
| ARI/Pneumonia in children | 660 (82.8) | 715 (89.7) | 0.000 |
| Family planning services | 769 (96.5) | 769 (96.4) | 1 |
| Screening/referral/follow up on TB patients | 667 (83.7) | 671 (84.1) | 0.785 |
| Provision of DOTS to TB patients | 643 (80.6) | ||
| NCD screening | 719 (90.2) | 650 (81.5) | 0.000 |
| Medicines for NCD patients | 559 (70.2) | 493 (61.8) | 0.000 |
| Routine ANC services by VHSND/UHSND/MCHN | 684 (85.8) | 659 (82.7) | 0.086 |
| RI by VHSND/UHSND/MCHN | 658 (82.5) | 575 (72.1) | 0.000 |
| Distribution of IFA to ANC/PNC cases | 0 | 766 (96) | NA |
| Counselling for family planning services | 0 | 787 (98.7) | NA |
|
| |||
| Beneficiaries | PW (n=708) | PNW (n=702) | |
|
| |||
| Received last ANC at home by ANMs | 2 (0.3) | 0 | |
| Received last ANC at a public health facility | 270 (38.3) | 0 | |
| Received last ANC at a private health facility | 261 (37) | 0 | |
| Received last ANC at a public health facility at a village/ward | 46 (6.6) | ||
| Delivered at home | 0 | 18 (2.6) | |
| Delivered at a public health facility | 0 | 501 (71.4) | |
| Delivered at a private health facility | 0 | 183 (26.1) | |
| Delivered at a private health facility/home due to delay in accessing services at public health facility | 0 | 2 (0.3) | |
| Delivered at a private health facility/home due to lack of services at a public health facility | 0 | 58 (8.3) | |
| Delivered at a private health facility/home due to lockdown (COVID-19) | 0 | 61 (8.8) | |
| Delivered at a private health facility/home due to preference | 0 | 77 (11.1) | |
| Received vaccination for the child after birth | 0 | 626 (89.3) | |
| Visited by ASHA during the postnatal period | 0 | 456 (65) | |
| Received IFA/Calcium in last two months | 0 | 563 (80.3) | |
| Received information/services related to family planning | 0 | 207 (29.5) | |
| Received a call to inquire about newborn’s health status | 0 | 219 (31.2) | |
A survey conducted among the beneficiaries demonstrated that approximately 82% of pregnant women received their last antenatal care (ANC) at a health facility. Among which, a similar proportion received it at public and private facilities. Around 98% of women delivered at a health facility, and more than two-thirds delivered at a public health facility. Commonly cited reasons for delivering at a private health facility or home were the individual preference, lockdown, and lack of facilities at a public health facility. Approximately 90% mentioned their child received vaccination after birth and around 80% received calcium in the last two months. Roughly two-thirds were visited by the ASHAs in their postnatal period, and less than one-third received family planning information and calls to inquire about their child’s health status. A detailed account of service delivery reported by the beneficiaries is depicted in Table 1.
Access to essential non-COVID services
Approximately 80% of ASHAs and ANMs reported that referral transport services were functioning as earlier. Less than one-fifth mentioned they were irregular or delayed, and a minor proportion stated their unavailability. Other lesser mentioned issues were the non-availability of services at a health facility, multiple referrals, and movement restrictions. The difference in response between ASHAs and ANM for these findings was not statistically significant. A detailed account of access reported by the FLWs is depicted in Table 2.
Table 2.
Access Indicators – Front-line Workers and Beneficiaries
| Front-line Workers | ASHA (n=798) | ANM (n=798) | P |
|---|---|---|---|
| Ambulance/transport services for delivery cases functioning as earlier | 656 (82.3) | 644 (80.8) | 0.439 |
| Ambulance/transport services for delivery cases were irregular or delayed | 99 (12.5) | 123 (15.5) | 0.182 |
| Non-availability of ambulance/transport services | 40 (5.1) | 28 (3.6) | 0.136 |
| Non-availability of services at the facility | 10 (1.4) | 12 (1.6) | 0.766 |
| Referral of patients to multiple facilities | 18 (2.4) | 15 (2) | 0.659 |
|
| |||
| Beneficiaries | PW (n=708) | PNW (n=702) | |
|
| |||
| Unable to access ANC in March-May due to challenges faced | 63 (9) | 0 | |
| ANM/ASHA did not inform | 9 (1.4) | 0 | |
| Unavailability of services at public/private health facility | 11 (1.7) | 0 | |
| Public/private health facility was closed | 13 (2) | 0 | |
| Restrictions of movement | 16 (2.4) | 0 | |
| Transport unavailability | 18 (2.7) | 0 | |
| Availed free ambulance services to go to the facility | 0 | 240 (34.2) | |
| Availed drop back facility | 0 | 169 (24.1) | |
| Faced problems during delivery due to delay in ambulance | 0 | 7 (0.9) | |
| Faced problems during delivery due to ambulance unavailability | 0 | 33 (4.8) | |
| Faced problems during delivery due to multiple referrals | 0 | 37 (5.3) | |
Around 9% of pregnant women were unable to access ANC due to the pandemic. Less than 3% of pregnant women mentioned they faced challenges due to transport unavailability, movement restrictions, health facility being closed, or unavailability of services at the private/public health facility, respectively. Issues regarding the availability of free referral transport were highlighted by the postnatal women; only one-third were able to avail it, and one-fourth had access to the drop-back facility. Around 5% of postnatal mothers faced problems due to ambulance unavailability or multiple referrals, respectively. More details on access reported by the beneficiaries are depicted in Table 2.
Facilitators and barriers in delivering essential non-COVID health services
The ASHAs were offered maximum support by the ANMs, followed by the ASHA facilitators and medical officer (MOs) at the health facilities. Only around 1% reported not receiving any support during the pandemic.
The FLWs faced several barriers while undertaking their roles. A univariate analysis conducted among the common variables showed that a higher proportion of ASHAs experienced problems than ANMs concerning their experiences with the community members (P = 0.000) and availability of services at the health facility (P = 0.000). A detailed account of the facilitators and barriers experienced by the FLWs is depicted in Table 3.
Table 3.
Facilitators and Barriers in Delivering Services
| Front-line Workers | ASHA (n=798) | ANM (n=798) | P |
|---|---|---|---|
| Maximum support by ANMs | 420 (52.8) | ||
| Maximum support by ASHA facilitators | 182 (22.9) | ||
| Maximum support by MO at PHC or UPHC | 62 (7.9) | ||
| Maximum support (Others) | 119 (15) | ||
| No support received | 10 (1.4) | ||
| Community members not understanding the importance of the COVID situation | 446 (56) | 346 (43.4) | 0.000 |
| Community members not giving full details during the survey | 383 (48.1) | 252 (31.7) | 0.000 |
| Community members not allowing them to visit | 342 (43) | 184 (23.1) | 0.000 |
| Restrictions in movement due to COVID-19 | 160 (20.2) | 147 (18.5) | 0.409 |
| Non-availability of transport services to go to PHC/or other health facilities | 395 (49.6) | 388 (48.7) | 0.725 |
| Non or limited availability of services at the public health facilities | 376 (47.2) | 236 (29.6) | 0.000 |
| Limited availability of time to work on other non-COVID activities | 286 (36) | 279 (35) | 0.714 |
| Violence or abuse faced in the community | 160 (20.2) | 146 (18.4) | 0.373 |
Knowledge and practices of front-line workers and beneficiaries
Approximately 92% of FLWs received training related to COVID-19, and around 99% were involved in awareness generation. While most of the FLWs and beneficiaries demonstrated adequate knowledge and COVID-19 appropriate behavior, findings varied across different variables. However, a greater proportion of beneficiaries demonstrated appropriate COVID-19 behavior as compared to the FLWs in most variables (P < 0.05). A detailed account is depicted in Table 4.
Table 4.
Knowledge and Practices Related to COVID-19
| Identified Themes | ASHA (n=798) | ANM (n=798) | PW (n=708) | PNW (n=702) | P |
|---|---|---|---|---|---|
| Awareness regarding the designated facilities offering delivery services to suspected/confirmed COVID-19 pregnant women | 473 (59.4) | 581 (72.9) | 0 | 0 | 0.000 |
| Involved in COVID-19 related activities: Awareness generation | 795 (99.7) | 786 (98.6) | 0 | 0 | 0.019 |
| Received training related to COVID-19 | 731 (91.7) | 734 (92.1) | 0 | 0 | 0.784 |
| Avoiding participation in social gathering | 537 (67.4) | 536 (67.2) | 544 (77) | 636 (90.7) | 0.000 |
| Staying at home as much as possible | 544 (68.3) | 528 (66.2) | 600 (84.9) | 641 (91.5) | 0.000 |
| Practicing social distancing/maintaining safe distance of at least 1 meter | 659 (82.7) | 731 (91.7) | 626 (88.6) | 654 (93.3) | 0.001 |
| Wearing masks | 747 (93.7) | 739 (92.7) | 581 (82.2) | 631 (90) | 0.000 |
| Covering face while sneezing/coughing | 489 (61.4) | 477 (59.8) | 639 (90.4) | 657 (93.7) | 0.000 |
| Frequently washing of hands with soap | 718 (90.1) | 708 (88.8) | 677 (95.8) | 682 (97.3) | 0.000 |
| Using hand sanitizer to clean hands (if available) | 594 (74.6) | 584 (73.2) | 648 (91.7) | 656 (93.6) | 0.000 |
| Avoiding touching eyes and mouth with unwashed hands | 438 (55) | 0 | 0 | 0 | NA |
| Avoiding touching/feeding baby with unwashed Hands | 0 | 0 | 0 | 605 (86.2) | 0 |
*Responses from FLWs (ASHA and ANM) and beneficiaries (Pregnant Women and Postnatal women) were combined for univariate analysis.
Discussion
The findings of the survey demonstrated that most essential services continued during the pandemic. Due to the higher susceptibility of women to COVID-19, several studies were conducted on evaluating the impact of COVID-19 on RMNCH services globally. Evidence denoted a significant reduction in maternal health service uptake during the pandemic, especially in low-resource settings such as in LMICs.[10] A study conducted in India reported a decrease in institutional deliveries[10]; however, the current study demonstrated that the majority of pregnant women delivered in a health facility. Additionally, they were well-supported by ASHAs during their delivery period, which potentially evades high-risk pregnancy. A facility-based descriptive cross-sectional study from Sri Lanka recorded a decline in ANC during the pandemic.[11] In contrast, the current study revealed that approximately 90% of pregnant women availed ANC without experiencing any challenges, which supports a descriptive study conducted in South Africa that established that the use of ANC remained relatively steady during the pandemic.[12] A minor proportion of women reported issues related to health facility and movement restrictions which supports a qualitative study conducted in rural Ethiopia on factors influencing ANC uptake.[13] Increased maternal mortality, neonatal mortality, and stillbirth were associated with a decline in service uptake of essential services due to lockdown measures and delay in referral transport by studies conducted in Nepal[14] and India.[15] But, the current study illuminated that obstructions to service uptake due to the discussed reasons were minor in India.
As the pandemic progressed, the World Health Organisation (WHO) and the United Nations Chidren’s Fund (UNICEF) recommended routine immunization (RI) programs to continue, but advised mass vaccination campaigns to be temporarily suspended. This recommendation was further endorsed by researchers at the London School of Hygiene and Tropical Medicine. In compliance, GOI issued guidance to ensure the delivery of essential health services, including those of RMNCH.[9] Regardless, RI services were noticeably disrupted globally, and LMICs witnessed a higher impact due to limited healthcare resources. Several studies conducted in India,[16] Pakistan,[17] Indonesia,[18] and Nigeria,[19] indicated significant reductions in immunization services during the pandemic. The current study contradicts the findings as the majority of FLWs successfully delivered RI services. Moreover, the study conducted in India collected data for seven days from primary health care facilities attached to medical colleges in India through a web-based survey undertaken by primary health care (PHC) managers and supervisors.[16] The current study, in addition to providing national-level data during the pandemic, includes data collected from both FLWs and the beneficiaries.
In addition to RI, abortion is a time-sensitive, essential healthcare service that one in four women needs during their lifetime. However, it is often termed as ‘‘elective’’ or ‘‘non-essential’’ in many countries. A review on the impact of COVID-19 on family planning services in India reported an unmet need for services related to family planning and abortion.[20] Although the current study sheds light on the status of family planning services during the pandemic, it is limited in scope in terms of abortion. Nevertheless, an inclusive rights-based health system response to circumvent preventable morbidity and mortality as a consequence of inadequate abortion services may be implemented for better health outcomes.
Another review focusing on the impact of the pandemic on maternal health services conducted in Pakistan demonstrated a significant effect on the availability of essential reproductive and maternal health-related medications such as vitamins and iron supplements.[21] In contrast, the current study reported that the majority of pregnant women received iron and folic acid IFA/Calcium supplements as a component of ANC. Efforts to disseminate important supplements should be continued to prevent fetal and maternal complications.
Previous literature has recommended strategies such as ‘ring-fenced community care’ to evade frequent hospital visits for pregnant women in Poland[22] or the ‘hospital within a hospital’ to meet the demands of the newly identified cases of COVID-19 while dealing with the safety of other patients in Dublin.[23] Additionally, robust virtual care pathways for ANC services were also recommended. These suggestions are in conformity with the guidelines documented by the MoHFW, GOI, and are continuously implemented, as illustrated by the findings of the study.
Current evidence on the impact of COVID-19 on communicable diseases predominantly focuses on tuberculosis (TB) and human immunodeficiency virus (HIV). The COVID-19 pandemic has been largely discussed as a possible impediment to the mitigation plans of TB and HIV. Reports from Africa[24] and India[25] have discussed how COVID-19 and TB can initiate a double health crisis by affecting TB case detection, creating diagnostic confusion, amplifying stigmatization, and worsening gender disparity. However, the current study informed that activities related to TB, such as screening, referral, follow-up, and provision of directly observed therapy (DOTs) to patients, were satisfactorily undertaken during the pandemic. As such, it may be inferred that control efforts to attenuate the potential effects of COVID-19 on TB were successfully implemented. The current study is limited in scope in terms of HIV data. Hence, future research may also focus on the impact assessment of COVID-19 on HIV, particularly in LMICs with an increased HIV disease burden.
Further, NCD prevention and management emerged as one of the pressing public health challenges during the pandemic. Services have been severely impacted globally, with LMICs witnessing the most disruptions. A WHO survey demonstrated that patients living with NCDs (PLWNCDs) were unable to access healthcare services in 155 countries; more than 53% of countries surveyed were experiencing partial or complete impairment of services and related complications.[26] Similar findings were reported by the media in LMICs through stories of PLWNCDs on how prolonged lockdowns have further exacerbated their chronic conditions. Investigations in India suggested that as issues in healthcare facilities increased manifolds, there was a lack of human resources, shortage of medical supplies, and diagnostics that could potentially have an adverse impact on access to healthcare services and treatment adherence by PLWNCDs.[26] Similar evidence was generated in LMIC such as Bangladesh, Brazil, Ghana, Iran, Pakistan, and Nepal.[26] The current study established that the provision of medicines for hypertension and diabetes patients was comparatively lesser as compared to other services, which strengthens the discussed literature. Given the current situation, it is advisable that FLWs/volunteers consider the possibility of doorstep delivery of medications during the period of the lockdown, provided patients are stable.[9] In the case of complications, patients may be advised to contact Community Health Officer (CHO)/Multi-Purpose Workers (MPW) where available or Primary Health Centre-Medical Officer (PHC-MO).[7] Other services pertaining to NCDs, such as referral services and health awareness, may be continued through helplines to minimize contact.
Minor issues emerged among the FLWs and the beneficiaries concerning access. Although this finding verifies existing literature demonstrating that access to essential health services was affected in LMICs,[4] it highlights that the extent of disruption with regards to access was much lesser in India as compared to other LMICs. Notwithstanding, the current study reinforces the need for efficient referral transport facilities and mechanisms across facilities.
Most ASHAs were well-supported during the pandemic but faced common barriers such as resistance from the community, issues with referral transport services, and limited or non-availability of services at the public health facilities. These findings strengthen existing literature on the impact of COVID-19 on healthcare workers in the United States, India, and Nepal.[27] It also underscored the need for individual and organizational resilience through training programs and adequate support to help the healthcare workers, particularly FLWs, to deal with the unprecedented stress of the pandemic.
Lastly, the FLWs and beneficiaries demonstrated adequate knowledge of COVID-19. This strengthens existing literature on knowledge about COVID-19 among healthcare workers and populations in India,[28] China, Italy, Iran, Jordan, the United States, the United Kingdom, and China, which reported considerable levels of knowledge on COVID-19.[29] Whilst the optimistic findings among beneficiaries, the FLWs continued to face resistance from the community. This raises concerns about the effectiveness of the awareness campaigns, which need to be evaluated to enhance behavior change communication. Findings on best practices of COVID-19 support existing literature that establishes mitigating local transmission, supporting, conserving, and supporting staff, eliminating non-urgent strains on the system, and coordinating communication as essential considerations to mitigate the COVID-19 pandemic.[30]
Conclusion
This paper reveals that despite the prevailing conditions posed to the Indian health system by COVID-19, it performed satisfactorily well during the pandemic in terms of essential non-COVID health services. Further documentation and research about varying experiences are essential to prepare as well as to adapt ourselves to similar situations now and in the future.
Financial support and sponsorship
Call Centre support was provided by the Mother and Child Tracking Facilitation Centre (MCTFC), Ministry of Health and Family Welfare (MoHFW), Government of India (GOI). Remuneration for additional callers (regional dialect) was supported by the National Health Systems Resource Centre (NHSRC), New Delhi.
Conflicts of interest
All authors are employees/associated with NHSRC, New Delhi, which is a technical support unit for the National Health Mission, MoHFW, GOI.
Acknowledgement
We would like to acknowledge the translators and callers at MCTFC for their support in the survey. Besides, we would like to express our sincere gratitude to Dr. Rajani R Ved, Former Executive Director, National health systems resource centre (NHSRC), for necessary technical suggestions in planning and executing the survey. We also thank the front-line workers and beneficiaries for participating in the survey.
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